Differential Diagnosis of Pain Around the Hip Joint

Current Concepts
Differential Diagnosis of Pain Around the Hip Joint
Lisa M. Tibor, M.D., and Jon K. Sekiya, M.D.
Abstract: The differential diagnosis of hip pain is broad and includes intra-articular pathology,
extra-articular pathology, and mimickers, including the joints of the pelvic ring. With the current
advancements in hip arthroscopy, more patients are being evaluated for hip pain. In recent years, our
understanding of the functional anatomy around the hip has improved. In addition, because of
advancements in magnetic resonance imaging, the diagnosis of soft tissue causes of hip pain has
improved. All of these advances have broadened the differential diagnosis of pain around the hip joint
and improved the treatment of these problems. In this review, we discuss the causes of intra-articular
hip pain that can be addressed arthroscopically: labral tears, loose bodies, femoroacetabular impingement, capsular laxity, tears of the ligamentum teres, and chondral damage. Extra-articular diagnoses
that can be managed arthroscopically are also discussed, including: iliopsoas tendonitis, “internal”
snapping hip, “external” snapping hip, iliotibial band and greater trochanteric bursitis, and gluteal
tendon injury. Finally, we discuss extra-articular causes of hip pain that are often managed nonoperatively or in an open fashion: femoral neck stress fracture, adductor strain, piriformis syndrome,
sacroiliac joint pain, athletic pubalgia, “sports hernia,” “Gilmore’s groin,” and osteitis pubis. Key
Words: Athletic groin injury—Chronic groin pain—Greater trochanteric pain syndrome—Hip
arthroscopy—Hip pain—Snapping hip.
W
ith the current explosion in hip arthroscopy
procedures, patients are being referred in ever
increasing numbers for the evaluation of hip pain.
Many of these patients are athletic and unwilling to
limit their activity or, in the case of a professional or
collegiate athlete, retire from their sport because of
their hip pain. As a result, in recent years, the understanding of the functional anatomy around this joint
has been improved and refined. In addition, advance-
From the Departments of Orthopaedic Surgery, University of
Michigan Hospitals (L.M.T.) and MedSport, University of Michigan Medical Center (J.K.S.), Ann Arbor, Michigan, U.S.A.
The authors report no conflict of interest.
Address correspondence and reprint requests to Jon K.
Sekiya, M.D., MedSport, Department of Orthopaedic Surgery,
University of Michigan Medical Center, 24 Frank Lloyd Wright
Dr., P.O. Box 0391, Ann Arbor, MI 48106-0391, U.S.A. E-mail:
[email protected]
© 2008 by the Arthroscopy Association of North America
0749-8063/08/2412-8249$34.00/0
doi:10.1016/j.arthro.2008.06.019
ments in magnetic resonance imaging (MRI) have
improved the ability to diagnose soft tissue causes of
hip pain. All of these advances have significantly
broadened the differential diagnosis of pain around the
hip joint and improved our treatment of these problems (Table 1).
Several conditions causing hip pain have only
recently become better understood. Pain around the
hip was often treated with prolonged conservative
management, such as activity restriction, and if that
failed, open procedures. Many of these patients are
currently being treated arthroscopically and are
having great success at returning fully to their activities, including sporting activities of all levels.
Not all causes of pain around the hip are intraarticular, however, and not all can be treated arthroscopically. The distinction between the various
causes of hip pain is important for treating these
patients. In this review, we discuss the various
causes of pain around the hip, the keys to making
the diagnosis, and evidence-based treatments.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 12 (December), 2008: pp 1407-1421
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L. M. TIBOR AND J. K. SEKIYA
TABLE 1.
Causes of Pain Around the Hip Joint
Intra-Articular
Extra-Articular
Hip Mimickers
Labral tears*
Loose bodies*
Femoroacetabular impingement*
Capsular laxity*
Ligamentum teres rupture*
Chondral damage*
Iliopsoas tendonitis*
Iliotibial band*
Gluteus medius or minimus*
Greater trochanteric bursitis*
Stress fracture
Adductor strain
Piriformis syndrome*
Sacroiliac joint pathology
Athletic pubalgia
Sports hernia
Osteitis pubis
*Condition can be treated arthroscopically.
INTRA-ARTICULAR CAUSES OF HIP PAIN
Labral Tears
Tears of the acetabular labrum are currently the
most common indication for hip arthroscopy.1 Degenerative labral tears were initially described in patients
with developmental dysplasia of the hip (DDH) and
degenerative osteoarthritis.2 Structural labral abnormalities with resultant labral pathology were subsequently described in a number of disorders, including
Perthes’ disease, previous trauma, previous slipped
capital femoral epiphysis, and in association with
femoroacetabular impingement (FAI).3,4 Of late, activities requiring repetitive pivoting or hip flexion
have also become a recognized cause of labral tears.3-5
As a result, athletes participating in hockey, football,
soccer, ballet, or running appear to be at increased risk
of labral tears.5
Patients generally have a gradual onset of symptoms, but they may occasionally relate the onset of
pain to a traumatic event.3,5 Most patients describe a
combination of dull and sharp groin pain, occasionally
with associated buttock pain.3 This is worse with
activity, walking, and prolonged sitting.3 About half
of patients describe associated catching or painful
clicking (mechanical symptoms).3,4 On examination,
they may ambulate with a Trendelenburg gait or limp
and often have a positive impingement sign.3 The
impingement test places the hip in 90° of flexion,
adduction, and internal rotation. It is considered positive if it produces groin pain.3 Patients often have
relief with an intra-articular injection.6 Radiographs
may show mild degenerative changes or an associated
condition like mild DDH, FAI, acetabular anteversion,3 or acetabular retroversion,4,7 predisposing the
patient to labral tears.6,8 The most reliable study for
diagnosis of labral tears appears to be small-field
magnetic resonance arthrography (MRA), which has
shown upwards of 90% sensitivity and 100% specificity in diagnosing labral tears.8,9 For patients who
cannot undergo MRA, contrast-enhanced computed
tomography (CT) has shown similar sensitivity and
specificity.10
Hip arthroscopy is indicated for patients with suspected labral tears based on clinical exam, MRA, and
persistent hip pain for more than 4 weeks.3,4,11 Good
short-term results have been described for both arthroscopic labral debridement and labral repair.3,7,11 Patients with structural abnormalities should undergo an
appropriate corrective procedure (e.g., femoral neck
osteoplasty/acetabular rim trimming with labral refixation [Fig 1] for FAI or pelvic osteotomy for significant DDH).3,4,7
Loose Bodies
Intra-articular loose bodies can be ossified or nonossified, osteochondral, chondral, fibrous, or foreign.12 They are frequently associated with other
pathologic processes occurring around the hip, including synovial chondromatosis, pigmented villonodular
synovitis, osteochondritis dissecans, degenerative osteoarthritis, and avascular necrosis.12 Patients who
sustain traumatic hip dislocations often also have intra-articular loose bodies following reduction.13,14
Lower-energy trauma causing chondral injury and
loose body formation has also been described.12 Arthrocopic removal of varied foreign bodies has been
described in the hip, including shrapnel and bullet
fragments, and iatrogenic foreign bodies including
needles, broken drain tubing, and polymethylmethacrylate cement.12
Patients describe mechanical symptoms including
catching, locking, clicking, or giving way. They may
have anterior groin pain or note hip stiffness.12,15
Occasionally, they have a history of dislocation or
other low-energy trauma.12-14 The most common find-
PAIN AROUND THE HIP JOINT
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FIGURE 1. Labral tears occur frequently in association with cam impingement, as shown in these T1- and T2-weighted MRI scans. (A) There
is increased offset at the femoral head–neck junction and asphericity (circle) resulting in the characteristic osseous “bump” (thick arrow) at
the head–neck junction as shown in the T1-weighted image. (B) The resulting labral pathology (longer thin arrow) at the anterior head–neck
junction is shown in the T2-weighted image of the same patient.
ings on examination are limited range of motion
(ROM), catching, or grinding. Ossified or osteochondral loose bodies are the most easily identified on
plain radiographs or CT scans because they are radioopaque.12,14 MRI with gadolinium contrast or MRA
are more useful for identifying cartilaginous loose
bodies and are useful for characterizing associated
synovial or soft tissue pathology (Fig 2).16
Symptomatic loose bodies within the hip can cause
the destruction of hyaline cartilage with resultant degenerative arthritis. Arthroscopy is the emerging gold
standard for removal of a loose body; open approaches
provide limited visualization of the articular surface
and are associated with considerable morbidity.17
Loose body removal is the most widely accepted
indication for hip arthroscopy,1 allowing simultaneous
inspection of the synovium and joint surface. Because
of the constrained nature of the hip, loose body removal can be technically challenging. Smaller pieces
can be removed with suction lavage, but larger fragments may require a Kerrison rongeur or pituitary
grasper instead of more delicate arthroscopy tools.12 If
an associated synovial condition is suspected, synovial biopsy or debridement may also be indicated.12
Femoroacetabular Impingement
Two types of FAI were described by Ganz18 as a
significant cause of hip pain and labral degeneration.
Cam impingement results from abnormalities at the
femoral head–neck junction, impacting the acetabulum and causing cartilage and labral wear.18-21 Pincer
impingement results from acetabular overcoverage,
resulting in impingement of a normal femoral head–
neck junction on the acetabular rim.18-21 The most
common type of FAI, however, occurs from mixed
cam and pincer pathology at the anterior femoral neck
and anterior-superior acetabular rim (Fig 3).18-20
Patients have sharp anterior pain with deep flexion, internal rotation, or abduction.19,20 In more
extensive lesions, patients may describe lateral or
posterior pain with external rotation, or pain with
stair-climbing and prolonged sitting.19,20 Athletes
may have difficulty squatting or difficulties with
lateral and cutting movements.20 FAI has been described most often in hockey players, but also occurs in golfers, dancers, football, and soccer players.22 On examination, patients have significantly
limited flexion and internal rotation.18,19 A positive
impingement test occurs with groin pain at 90° of flexion
and maximal internal rotation.19-22 The figure-of-four or
flexion-abduction-external rotation (FABER) maneuver
is tested with the patient in the supine position on the
exam table. It is considered positive if the distance between the lateral knee and exam table differs between the
symptomatic and contralateral hip, or if the maneuver
elicits groin pain.20
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L. M. TIBOR AND J. K. SEKIYA
FIGURE 2. Synovial chondromatosis is one cause of multiple symptomatic loose bodies within the hip joint. Magnetic resonance imaging
with gadolinium contrast or magnetic resonance arthrogram is useful for identifying cartilaginous loose bodies. (A) Sagittal and (B) axial
T1-weighted magnetic resonance imaging scans of synovial chondromatosis in the hip. Arrows indicate loose bodies within the joint capsule.
(A, acetabulum; FH, femoral head; GT, greater trochanter; I, ischium.)
Patients with suspected FAI should undergo anteroposterior pelvis and cross-table lateral radiographs to
assess for the characteristic “pistol-grip” femoral head
in cam impingement, or for acetabular retroversion
and crossover in pincer impingement.19-21 MRI and
MRA are also indicated for measurement of the alphaangle, quantifying the asphericity of the femoral head,
and for the evaluation of resultant labral tears, cartilage damage, and fibrocystic change at the femoral
head–neck junction.19,20
Surgical treatment of FAI is performed to improve
clearance for hip motion and relieve femoral head
abutment on the acetabular rim.21 Open treatment of
FAI involves surgical hip dislocation and osteoplasty,
with full visualization of both the femoral head and
acetabular rim.18 Open surgical dislocation is associated with a longer recovery time and a delayed return
to sporting activities.23 Arthroscopic osteoplasty for
both cam and pincer impingement has been described
for professional athletes with good results.21 Hip arthroscopy for FAI begins with confirmation of impingement from the peripheral compartment, and
evaluation and treatment of associated labral or chondral pathology.19-22 Burr osteoplasty of up to 30% of
the femoral neck, taking care to avoid the lateral
epiphyseal vessels, is performed for cam impingement
FIGURE 3. (A) Cam femoroacetabular impingement demonstrating decreased offset at the femoral head–neck junction. (B) In flexion and
internal rotation, the aspherical portion of the head produces shear at the cartilage/labrum transition zone, causing peripheral cartilage
damage. (C) Pincer femoroacetabular impingement demonstrating local and/or global acetabular overcoverage. (D) In flexion, the femoral
neck abuts the acetabular rim, crushing the labrum. Over time, chronic leverage of the head in the acetabulum results in a “contre-coup”
chondral injury to the posterior-inferior acetabulum. (Reprinted with permission.19)
PAIN AROUND THE HIP JOINT
1411
FIGURE 4. (A) Arthroscopic image of the impinging osseous lesion
(arrowhead) characteristic of cam femoroacetabular impingement at
the femoral head–neck junction, abutting the labrum (L) and causing
a (now-repaired) labral tear (asterisk). (B) Arthroscopic burr osteoplasty (closed arrowhead) of the lesion relieves the labral impingement. (C) Arthroscopic image of the hip in flexion, demonstrating
relief of labral (L) impingement following arthroscopic burr osteoplasty (closed arrowhead). The asterisk indicates the labral repair.
(Fig 4).19-22 Pincer impingement involves trimming of
the acetabular rim with takedown and subsequent repair of the acetabular labrum.19-22 Following arthroscopic debridement, 93% of a series of professional
athletes returned to their previous level of play, although their average time to return was not described.22 More recently, 75% of patients undergoing
arthroscopic treatment for FAI had good to excellent
results 1 year postoperatively.24
Capsular Laxity
Capsular laxity of the hip is an emerging concept
and remains somewhat controversial.1,25-27 The hip
has intrinsic osseous stability augmented by the labrum and capsuloligamentous structures.25,28,29 Secondary muscular stabilizers include the iliopsoas anteriorly.25,28 Traumatic laxity or instability results
from an acute dislocation event causing stretching of
the capsule or labral damage and predisposing the
patient to recurrent dislocation.25,26,29 Traumatic subluxations may be the result of lower-energy trauma,
and are more difficult to diagnose.25 Atraumatic instability can occur as a consequence of overuse or repetitive rotation with axial loading. These movements
result in so-called microinstability and are a described
cause of labral injury.4,25 Certain patients may also be
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L. M. TIBOR AND J. K. SEKIYA
FIGURE 5. A loose and redundant
hip capsule can be the cause of, or
can result from, atraumatic instability. Furthermore, analgous to
the shoulder, this can result in secondary impingement and associated anterior labral tearing. For patients with continued hip pain
despite conservative management,
arthroscopic capsulotomy (A) with
subsequent labral repair and capsular plication through the lateral and
medial iliofemoral ligaments (B)
can restore joint stability and resolve pain.
predisposed to instability, particularly those with generalized ligamentous laxity, acetabular dysplasia, or
labral pathology.4,25,26
Traumatic hip dislocation is not subtle; low-energy
mechanisms include a forward fall on the knee with
the hip flexed, while the classic high-energy mechanism is a dashboard motor vehicle accident. Hip subluxation occurs from a lower-energy forward fall on
the flexed knee and hip. These patients present with
painful and limited ROM on exam. Patients with more
chronic hip instability may be able to voluntarily
sublux or dislocate their hip. Stretch of the capsular
structures can cause anterior hip pain and is tested
with prone passive extension and external rotation.25,26
Athletes who play sports involving axial loading
and hip rotation may develop atraumatic hip instability and resultant hip pain.25-28 Golfers note pain with
a golf swing during a drive, and football players
describe pain while throwing to the sideline. On examination, these patients also have anterior hip pain
with prone passive extension and external rotation.25,26 With capsular laxity, the iliopsoas may become a more important dynamic stabilizer, resulting
in stiffness, localized pain, or even flexion contracture.25
Anteroposterior pelvis, Judet, and frog-lateral radiographs should be obtained for all capsular laxity patients.25 In patients with more subtle symptoms, predisposing anatomic factors, namely acetabular version
and subtle dysplasia, should be assessed. MRI or
MRA may be indicated to show labral tears, microfracture, or femoral head contusions, iliofemoral ligament disruption, joint effusions, and cartilage lesions.25,26 Some authors also advocate repeat MRI just
before planned hip arthroscopy to evaluate for early
avascular necrosis before placing the patient in traction.25
The treatment of acute traumatic dislocations with
associated fracture is well described in the literature,
and will not be addressed further in this review. For
subluxation or dislocation without associated fractures, the patient should remain toe-touch weight bearing on the affected side for 6 weeks. They can, however, begin early active and passive ROM as tolerated,
avoiding flexion past 90° and internal rotation more
than 10°.25,26 Intra-articular loose bodies are an indication for open or arthroscopic debridement.1,14 Arthroscopic labral and posterior capsular repair may be
helpful for patients with recurrent hip dislocation.25,26
Patients with suspected atraumatic instability
should undergo a trial of nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy.25 If hip
pain persists, arthroscopy may be indicated for labral
repair and capsular plication (Fig 5).25 Although good
results have been reported for this procedure,26 caution is warranted in patients with generalized ligamentous laxity, avascular necrosis on MRI, or significant
dysplasia. The latter group may require open bony
procedures to address their dysplasia.25
In addition, there is a subset of patients with capsular laxity that also develop secondary impingement
PAIN AROUND THE HIP JOINT
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FIGURE 6. (A) Extracapsular arthroscopic image of capsular laxity and secondary femoroacetabular impingement following capsulotomy
and osteoplasty (closed arrow) for cam impingement. (B) Analgous to the treatment for shoulder laxity, capsular plication with nonabsorbable
suture (asterisk) is performed after labral repair and other intra-articular procedures. In this image, a second, completed, plication stitch is
visible in the background. (C, capsule; FH, femoral head.)
signs, and may require concomitant FAI surgery.27
This is analogous to secondary impingement in the
multidirectionally lax shoulder where occult recurrent
humeral head subluxation causes rotator cuff and biceps tendon impingement on the acromion (Fig 6).30
Ligamentum Teres Tears
Lesions of the ligamentum teres are of unclear
significance and are often described in association
with other conditions.31-33 Three types of tears have
been described: complete tears associated with dislocation, partial tears associated with a subacute event, and
degenerative tears associated with joint pathology.31,34
Associated pathology includes avulsed bone or cartilage
fragments and labral tears.31-33
Patients describe nonspecific symptoms of catching,
popping, locking, or giving way.31,33 Exam findings
are also nonspecific, although the hip joint should be
definitively identified as the source of symptoms.1,33,34
Patients should have pain with hip logroll and may
obtain relief with an intra-articular injection.33,34 On
arthroscopy, the ruptured ligament should be debrided
and the associated conditions (e.g., loose bodies or
labral tears) should be addressed.33
Chondral Damage
Chondral damage in the hip has multiple traumatic
and atraumatic etiologies. These include labral tears,
loose bodies, dislocation, FAI, avascular necrosis, acetabular dysplasia, and previous slipped capital femoral epiphysis.35,36
Symptoms are often nonspecific. Patients may report mechanical symptoms consistent with degenerative labral pathology or generalized pain, stiffness,
and decreased ROM consistent with an inflammatory
process.35 Patients may have a history of trauma,
athletic activity, or a generalized inflammatory disorder.35 On examination, the position of the hip at rest
should be noted; abduction, flexion, and external rotation provide the most capsular volume and suggest
an effusion or synovitis.35 Gait, leg-length discrepancy, ROM, and impingement should be assessed.35
Degeneration is often seen on plain radiographs of
the affected side and is a poor prognostic sign.37,38
MRI is useful for evaluation of associated soft tissue
pathology. MRA is more specific for labral pathology
and chondral lesions than traditional MRI, although
the gold standard for assessing cartilage pathology in
the hip remains arthroscopy.7,8,35
Arthroscopy is useful for assessing cartilage damage and addressing soft tissue pathology. Microfracture can be considered in focal or contained
lesions less than 2 to 4 cm in diameter on the weight
bearing surface.35,36 It is contraindicated for partial
thickness defects, in lesions with associated bony
defects, and for patients more than 60 years of
age.35,36 Any unstable or calcified cartilage should
be debrided, taking care to maintain subchondral
integrity.35,36 Microfracture holes are made with an
awl, analogous to techniques described for the
knee.35,36 For cases where the articular cartilage has
started to peel off of the anterior acetabular rim and
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L. M. TIBOR AND J. K. SEKIYA
FIGURE 7. In cam femoroacetabular impingement, acetabular cartilage delamination results from continued shear forces with the hip
in flexion. (A) Arthroscopic image of acetabular cartilage delamination (straight arrow) adjacent to a labral tear (repaired, bent open
arrow). (B) The base of the lesion can be microfractured and repaired
with a polydioxanone suture (asterisk). (C) Completed cartilage
repair (asterisk) directly overlying the labral repar (bent open arrow).
(A, acetabulum; FH, femoral head; L, labrum.)
delaminate, options include microfracture of the
base and suture repair of the cartilage (Fig 7).
Postoperatively, continuous passive motion can be
used, and patients should remain toe-touch weight
bearing on the affected side for 6 to 8 weeks, advancing to full weight bearing after 8 weeks.35,36 Initial
physical therapy focuses on regaining ROM, progressing to regaining muscular endurance, and finally regaining power and strength. The return to impact
sports is delayed for at least 4 to 6 months postoperatively.35,36 In a small study of second-look arthroscopy patients an average of 20 months after the initial
arthroscopy, the investigators observed a 91% fill rate,
ranging from 25% to 100%.36 Unfortunately, the prognosis for patients with degenerative lesions undergo-
ing arthroscopy is poorer than that for patients with
other diagnoses, and these patients frequently progress
to arthroplasty.37,38
EXTRA-ARTICULAR CAUSES OF HIP PAIN
Iliopsoas Tendonitis and Internal Snapping Hip
There are 3 types of coxa saltans or snapping hip:
intra-articular snapping caused by several conditions,
including loose bodies and labral pathology; internal
snapping caused by the iliopsoas tendon moving over
a bony prominence; and external snapping from the
iliotibial (IT) band or gluteus maximus tendon snapping over the greater trochanter.39-41
PAIN AROUND THE HIP JOINT
Internal snapping of the iliopsoas tendon over the
iliopectineal eminence, femoral head, or lesser trochanter may or may not be painful. A greater incidence of snapping hip has been noted in ballet dancers, although it is often not bothersome in this
population.39 In a series of athletes with groin pain,
iliopsoas tendonitis was the most common cause of
groin pain in runners.42 Pain or discomfort associated
with internal snapping is an indication of associated
iliopsoas tendonitis, either as a result of acute inflammation or more chronic degeneration and tendinopathy.40,41
Patients report anterior groin pain associated with
extending the hip from a flexed position, and intermittent catching, snapping, or popping of the hip.40,41
Because the iliopsoas is also a flexor of the trunk on
the hip, iliopsoas tendonitis may occasionally present
with associated low back pain.43 On examination, the
iliopsoas tendon is tender to palpation or may be
painful with resisted hip flexion.40,41 Moving the patient from the FABER position into extension, adduction, and internal rotation often elicits a palpable
snap.39-41,44
Ultrasound examination by a trained musculoskeletal examiner may show tendinopathy with thickening
or hypoechogenicity within the tendon, bursitis with
fluid surrounding the tendon, or increased blood flow
with color Doppler imaging.40,41 Dynamic ultrasound
is also diagnostic as the tendon can be seen snapping
over the iliopectineal eminence.39-41
Initial management of painful iliopsoas tendonitis
consists of NSAIDs and physical therapy.41-44 If
patients continue to have pain, an ultrasound-guided
injection with lidocaine and corticosteroid can provide relief and predict the response to surgical release.40,41 For patients who have recurrent pain after
local injection, arthroscopic release at the musculotendinous junction or near the tendon insertion on
the lesser trochanter has been described with good
results.40,41,44,45
1415
disorders which cause gait alterations and the resultant
trochanteric bursitis.46,47
Patients describe pain over the greater trochanter
radiating down the lateral thigh, and may have difficulty lying on their side because of direct compression
of the bursa.46 The disorder is more common in middle-aged women46-48; however, it has been seen in
younger populations and may be more common in
runners.46,48 On examination, patients have pain with
direct compression of the trochanteric bursa.46,48 The
Ober test for IT band tightness is performed with the
patient lying on the nonaffected side and the knee
flexed to 90°, as the symptomatic hip is brought from
abduction to adduction.39,48 Often, snapping can be
elicited with the patient lying on his or her side as the
hip is brought from flexion to extension and internal to
external rotation.39 Gait should also be evaluated,
because an associated back or hip abnormality affecting gait can result in bursitis.46,47
Plain radiographs can be obtained to evaluate any
suspected intra-articular pathology; they occasionally
show calcifications within the bursa, but are generally
negative.46,48 Dynamic ultrasound is useful, because
the IT band can be seen snapping over the greater
trochanter. Associated bursitis or gluteal tendinopathy
can be assessed at the same time.39,44 Small-field MRI
has been used as the gold standard, but is not necessary to make the diagnosis of trochanteric bursitis.46-48
Greater trochanteric bursitis and painful external snapping should initially be managed nonoperatively with
rest, NSAIDs, and stretching or physical therapy.46,48 An
injection of corticosteroid or local anesthetic into the
trochanteric bursa may calm the associated inflammation
and provide diagnostic information if the patient has
relief with injection.46-48 Surgical IT band release or
debridement of the bursa is indicated if the patient has
continued symptoms after 6 months of nonoperative
therapy.48 Although this has classically been described as
an open procedure, arthroscopic trochanteric bursectomy
and IT band release has been described with good results
at an average of 1 year postoperatively.46,48,49
Iliotibial Band/Greater Trochanter Bursitis and
External Snapping Hip
Gluteus Minimus and Medius Injury
External coxa saltans is less common than internal
or intra-articular coxa saltans and is, as mentioned
previously, a result of a thickened IT band or gluteus
maximus tendon snapping over the greater trochanter.39-41 The repetitive friction between the greater
trochanter and IT band can, over time, cause inflammation of the interposing bursa and trochanteric bursitis.46 These patients often have spinal or other hip
The greater trochanter and gluteal tendons have
been compared to the rotator cuff of the shoulder.50-52 As in the shoulder, tendinopathy and subsequent tearing of the gluteal tendons may represent
a progression of injury and degeneration, from tendonitis and edema to progressive tendon thickening,
partial tearing, and ultimately to complete avulsion
or tearing at the gluteal insertion.50,52 The condition
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L. M. TIBOR AND J. K. SEKIYA
is more common in women, perhaps because of the
wider female pelvis.50-52
Patients present with dull lateral hip pain, focal
tenderness at the gluteal insertion, and weak hip abduction.51 Other provocative tests include passive and
resisted external rotation with the hip flexed to 90°,
and pain on one-leg stance for 30 seconds or more.51
Although patients should have plain radiographs taken
of the affected side, these are generally negative, and
only occasionally show calcification at the tendon
insertion.50 MRI findings are based on the severity of
injury. Tendon pathology is most commonly seen near
the insertion on the greater trochanter. The earliest
stage is thought to be peritendonitis, with adjacent soft
tissue edema and intact tendons, progressing to tendinosis as evidenced by increased signal within the
tendon and tendon thickening. MRI can distinguish
between partial and complete tears and evaluate fatty
atrophy of the gluteal muscles and calcification at the
tendon insertion.50 Ultrasound can also be used for
evaluation, particularly as tendon thickening and increased fluid can be directly correlated to the site of
pain.50
As in the treatment of trochanteric bursitis, the
initial management of gluteal tears should consist of
nonoperative measures, including physical therapy
and diagnostic or therapeutic injection.49,51 A technique for endoscopic repair of gluteus medius and
minimus tears has been described; however, no results
have been published evaluating the efficacy of this
approach.49
Stress Fracture
No arthroscopic management has yet been described for the treatment of stress fracture. These
fractures have been subdivided into 2 categories: fatigue fractures, which occur when normal bone is
subject to repeated abnormal stresses, and insufficiency fractures, which occur when normal stress is
applied to abnormal bone.53,54 The femoral neck was
the most common location of stress fracture in the
pelvis or femur,55 although stress fractures of the
sacrum, pubic rami, acetabulum, and femoral head can
also occur.55 Within the femoral neck, fractures located to the superior surface are under tension and are
at risk of displacement because they are mechanically
unstable.53,54 Conversely, fractures on the inferior surface of the femoral neck are under compression and
are mechanically stable.54
Patients present with exercise-induced pain in the
hip, groin, or thigh, or they may have referred pain to
the knee.53,56 In several studies, female gender and
amenorrhea, low aerobic fitness when starting an intense exercise program, smoking, and steroid use have
been associated with an increase risk of stress fracture.53,56 There may be no specific findings on physical examination other than diffuse radiating pain localized to the hip or groin.55 Although all patients
should have plain radiographs of the affected side,
these may have only 10% sensitivity if symptoms are
relatively early.53,55 MRI and bone scan are more
sensitive, although in one large series, the median time
from the onset of symptoms to the diagnosis of fracture from MRI was still 30 days.53,55
Tension-sided femoral neck fractures should be
pinned to prevent displacement and subsequent avascular necrosis.54 Compression-sided femoral neck
fractures can be treated with 6 to 8 weeks of limited
weight bearing.54 At an average of 18 years follow-up,
there was no higher incidence of avascular necrosis or
osteoarthritis in patients who had sustained a nondisplaced femoral neck fracture.54
Adductor Strain
Adductor longus strain is a significant cause of
groin pain in athletes, particularly in hockey, soccer,
and rugby players,42,57-60 and arthroscopic management is not indicated for this condition. As a whole,
the adductor muscle group acts with the lower abdominal muscles to stabilize the pelvis during lower extremity activities.57 Athletes participating in sports
that require repetitive kicking, quick starts, or changes
in direction have a higher incidence of chronic groin
pain and adductor muscle strain.43,57-60 The origin of
the adductor longus at the pubic symphysis has a
relatively smaller tendon area compared to that of the
muscular attachment, which may predispose this area
to strain.57 In addition, there is some evidence that
athletes with adductor weakness, abductor–adductor
imbalance, or decreased preseason hip ROM are more
predisposed to groin strain during the season.58,61
Patients typically present with aching groin or medial thigh pain and may or may not relate a specific
inciting incident57; however, acute rupture and osseous avulsion of the proximal adductor longus has also
been reported.62 On examination, there is tenderness
to palpation with focal swelling along the adductors
and decreased adductor strength and pain with resisted
adduction.42,57,59 The diagnosis can be made with focal findings on examination42; however, MRI with
gadolinium may be useful to confirm the diagnosis or
PAIN AROUND THE HIP JOINT
differentiate between adductor strain, osteitis pubis,
and sports hernia.59,60
Management is nonoperative with rest, ice, compression, and gentle physical therapy or ROM.57,59
Injection at the adductor longus enthesis is helpful for
patients refractory to conservative management.59 In
cases of acute rupture, open surgical repair with suture
anchors has been described with good results.62 Patients may return to sports or other activities after
regaining full strength and ROM with resolution of the
pain.57 Given the predisposition to adductor strain in
the setting of muscle imbalance, attention should be
given to preseason adductor strengthening and hip
ROM to prevent in-season groin strain injury.59,61
Piriformis Syndrome
Sciatic nerve compression and irritation by the piriformis muscle is a potential cause of lower back and
posterior thigh pain.63-65 There is 1 described arthroscopic technique67; however, most authors describe
nonoperative or open management of this condition.63-66 Piriformis syndrome can be caused by anatomic variations in either the muscle or the nerve,
piriformis hypertrophy or spasm, and muscular fibrosis following trauma.63,64 Classically, the sciatic nerve
emerges from the greater sciatic notch below the piriformis muscle; however, the anatomy is quite variable, and the nerve can split above the piriformis, with
1 or 2 branches emerging above, through, or below the
muscle.63
Patients with suspected piriformis syndrome describe pain at the sacroiliac joint or sciatic notch.63,66
They frequently have leg pain radiating from the hip
down to the foot or ankle in the sciatic nerve distribution.63-66 In comparison to radicular causes of sciatica, numbness or weakness may be rare.68 Sitting on
a hard surface or for long periods of time worsens the
pain, while walking relieves the compression and
pain.63,65,66 There is generally tenderness to palpation
at the sciatic notch or greater trochanter.63-66 Occasionally, a spindle-shaped mass in the region of the
piriformis can be palpated.63 Symptoms can be reproduced with resisted abduction or adduction of a flexed
and internally rotated thigh, also known as the Lasegue, Freiburg, or Pace signs, which place the sciatic
nerve on stretch.63-66 In contrast to patients with radicular causes of sciatica, the straight-leg raise is
frequently negative.66
Patients with piriformis syndrome have often already been evaluated for possible nerve root impingement. An MRI of the lumbar spine will fail to show
1417
any disk herniation, whereas an MRI of the pelvis may
show piriformis muscle atrophy or hypertrophy and
edema surrounding the sciatic nerve at the level of the
piriformis.65,66
Treatment of piriformis syndrome begins with
NSAIDs, muscle relaxants, and gentle physical therapy to relieve muscle spasm and associated nerve
inflammation.63-66 For patients with persistent pain,
ultrasound or magnetic resonance– guided local injection may be both diagnostic and therapeutic.64,66 In a
large case series, some patients had resolution of
symptoms after 1 or 2 injections66; for patients with
only transient relief, injection appeared to be predictive of the results following surgical release.66 For
these patients, surgical release of sciatic compression
via a transgluteal approach was associated with good
results.66 Endoscopic piriformis release has also been
described in a small series, with good short-term results.67
HIP MIMICKERS
Sacroiliac Joint Pain
The sacroiliac (SI) joint is a synovial joint with a
fibrous surrounding capsule. The anterior and posterior capsules are relatively thin, but are augmented by
the interosseous ligament posteriorly and the anterior
joint ligament, which blends into the iliolumbar ligaments.68 Joint morphology changes with age. Flat
joint surfaces are present before puberty, but with age,
bony elevations and depressions develop to enhance
joint stability.68 The synovial cleft also narrows progressively, with ankylosis in some patients over 50
years of age.68 There are multiple possible etiologies
of SI joint pain, including hyper- or hypomobility,
cumulative trauma, degenerative arthritis, infection,
ligamentous strain, stress fractures, and sacroilitis or
inflammatory arthropathies.68 There are no indications
yet described for SI joint arthroscopy.
SI joint pain is referred to the area near the posterior
superior iliac spine; most patients report buttock pain
that may radiate into the thigh and may be mistaken
for discogenic sciatica.69,70 Patients may have tenderness along the SI joints or sacral sulcus; however,
there is no scientific validity to the currently described
provocative examination maneuvers for SI joint pathology.68-70 It is important to perform a complete
neurologic exam to exclude other potential pathologies (e.g., L5 radiculopathy or tumor).68-70
Plain anteroposterior, inlet, and outlet radiographs of the pelvis should be obtained. If SI joint
1418
L. M. TIBOR AND J. K. SEKIYA
instability is suspected, single-leg stance views
should be obtained, looking for displacement.68 CT
scan, MRI, and bone scans can be obtained to
evaluate specific etiologies of SI joint pain, although these are not specific for idiopathic pain.68-70
Complete relief of pain after image-guided SI joint
injection is considered diagnostic.68-70
Treatment depends on the etiology of the SI joint
pain. Physical therapy to identify and correct flexibility and strength deficits is appropriate, with use of
modalities limited to the acute phases of pain.68 There
is evidence that vertical shear loads on the SI joint can
be minimized by strengthening of the rectus abdominus and pelvic floor musculature, reducing SI joint
pain.71 Medical management should include antirheumatic agents for patients with spondyloarthropathies
and NSAIDs for more limited inflammation.68,70 Image-guided cortisone injections are indicated after 4
weeks of conservative management, but may be useful
for confirming the diagnosis earlier.68-70 Pelvic belts
can provide some pain relief and limit motion of the SI
joint by up to 30%.68 Manipulation is contraindicated
in sacral stress fractures and ideally is used only for a
limited time as the patient transitions to a structured
exercise program.68,69 More invasive therapies include
radiofrequency neurotomy and surgical arthrodesis.
These therapies are controversial, and should only be
considered for patients with confirmed SI joint pain
who have not improved following less invasive therapies.68,70
Athletic Pubalgia/Sports Hernia/Gilmore’s Groin
Another cause of chronic groin pain in athletes has
variously been termed athletic pubalgia, sports hernia,
and rectus abdominus injury.72-74 There is debate as to
the exact etiology of this condition. One larger series
defined athletic pubalgia as disabling lower abdominal
and inguinal pain possibly resulting from a hyperextension injury to the rectus insertion on the pubic
symphysis, destabilizing the anterior pelvis.75 It has
alternatively also been described as an occult hernia
caused by weakness or tearing of the posterior inguinal wall without a clinically recognizable hernia.73,74
Gilmore’s groin is a subset of this, consisting of tears
in the external oblique aponeurosis and conjoint tendon, with dehiscence between the conjoint tendon and
inguinal ligament.73 This condition can be managed
with endoscopic mesh repair, typically by a general
surgeon.72-75 Sports requiring repetitive twisting and
turning of the proximal thigh and lower abdomen
(e.g., ice hockey, soccer, skiing, rugby, and tennis)
may have a higher incidence of sports hernia.72-75 It is
thought to result from simultaneous trunk hyperextension and thigh hyperabduction leading to shearing
across the pubic symphysis.73 Athletes with muscular
imbalance between strong thigh muscles and weaker
abdominal muscles may have higher shearing forces
across the symphysis and may be more prone to this
injury.73
Patients typically have an insidious onset of pain
with activity, resolving with rest, and radiating into
the adductor, perineum, rectus, inguinal ligament, or
testicular areas.73,74 This is aggravated by sudden
movements— coughing, sneezing, sit-ups, sprints, or
kicking— ultimately limiting their performance.73,74
On examination, there is no detectable hernia, although they may have tenderness around the conjoined tendon, pubic tubercle, superficial inguinal
ring, or posterior inguinal canal.73-75 They may have
pain with resisted sit-ups, hip adduction, or the Valsalva maneuver.73-76 In one study, MRI was found to
be sensitive and specific for both rectus abdominus
and adductor tendon injuries.72 Other studies, including radiographs, ultrasound, or bone scan, should be
used as necessary to rule out other etiologies of
chronic groin pain.73
Treatment initially consists of NSAIDs, icing after
activity, massage, and rest, with gradual return to
activity if the pain improves.73,74 Physical therapy
should focus on core strengthening and improving hip
or pelvic muscle imbalances.73 Surgical exploration
and repair of the weak posterior inguinal wall or
pelvic floor is indicated after 6 to 8 weeks of targeted
nonoperative therapy.72-75 Both open and laparoscopic
repairs have been described, with or without the use of
mesh.72-75 The results of repair and return to play
thereafter are generally good. Most patients return to
full activity within 2 to 6 weeks of laparoscopic repair
and 1 to 6 months after open repair.72-75
Osteitis Pubis
The definition of osteitis pubis continues to be debated in the literature and varies from overuse and
functional pelvic instability76 to a term reserved for
describing complications following retro- or parapubic surgery.42 No arthroscopic management for this
condition has been described. It is one cause of
chronic groin pain in sports requiring significant twisting, turning, or kicking.61,72,76,77 Several etiologies
have been proposed in the athletic population including adductor or rectus injury,72,77 overuse,76 or anterior instability.76 In addition, there may be a correla-
PAIN AROUND THE HIP JOINT
tion between decreased preseason hip rotational ROM
and the development of osteitis pubis.61 Osteitis pubis
has also been described in pregnant and postpartum
females, patients with rheumatologic disorders, and
with infection following urologic or gynecologic procedures.78
Patients present with sharp or aching anterior pelvic
pain located over the symphysis.76-78 This may radiate
into the lower abdominal muscles, perineum, or thigh
adductors, and they may describe associated adductor
spasm.76-78 On examination, they have tenderness
with palpation over the symphysis and pubic rami and
pain with adductor stretching and rising from a seated
position.76-78
In relatively acute cases, plain radiographs may be
normal; however, in chronic cases, radiographs can
show cystic changes, sclerosis, and widening or narrowing at the symphysis.76,78 Instability may be evident on a one-legged stance film.76 Bone edema spanning the symphisis with cystic or other degenerative
changes or adductor microtears may be visible on
MRI.60,72,76-78 Bone scan may show increased uptake
at the symphysis, although can take months to become
positive in some athletes.76-78
Nonoperative management is similar to other causes
of chronic groin pain and includes NSAIDs, physical
therapy focusing on core stability, muscle balance,
and rotational hip ROM, and activity modification.60,61,72,76,77 Local corticosteroid injection may be
diagnostic for localizing pain and provide some therapeutic benefit.72,76,78 The results of injection are often
transient, but may be predictive of the response to
surgery.76 Surgical options for patients who have an
incomplete response to less invasive therapy include
wedge resection at the symphysis, symphsiodesis,
posterior wall mesh repair, or curettage.76-78 In an
athletic population, curettage was associated with
complete or near complete resolution of symptoms in
nearly 80% of patients.76 A case series described early
return to sport following mesh reinforcement of the
posterior pubic area in elite athletes.77 In a small
nonathletic series of patients with osteitis pubis, the
results of wedge resection and arthrodesis were less
predictable.78
CONCLUSIONS
The differential diagnosis of pain around the hip
and groin is broad and includes intra-articular pathology, extra-articular soft tissue and tendon pathology,
and mimickers, including the joints that make up the
pelvic ring. Many potential causes of hip pain have
1419
overlapping symptoms or physical exam findings. A
careful history and physical examination in combination with appropriate imaging and diagnostic or therapeutic injections generally leads to the correct diagnosis and appropriate therapy.
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